Referral - Mediation Associates

Prefer to email or post?

Would you prefer to email us or send us a letter by post? If so, click the button below to download a Microsoft Word version of the referral form which can be attached to an email or sent to us by post.

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Referral Form

Client 1

Name (required)

Address (required)

Telephone number (required)

Email (required)

Date of Birth

Relationship to child

Client 2

Name

Address

Telephone number

Email

Date of Birth

Relationship to child

Child(ren)'s Details

Issues for mediation? Child issuesProperty & FinanceAll Issues

Does the client(s) have any special requirements (e.g. Wheelchair access, interpreter, health issues)?

Any other information or details of which you think we should be aware?

Privacy note - Please note that by completing this referral form you are giving consent to Mediation Associates to hold limited personal information in order to enable you to get access to the mediation information and assessment process introduced by the Children and Families Act 2014, s 10). This information will be held securely and will only be used for the purpose of providing information or mediation and where appropriate securing legal aid. You can request your data be removed from our systems by contacting us in writing.

Mediation Associates

Prefer to email or post?

Referral Form

Client 1

Client 2

Child(ren)'s Details

First Name

Surname Name

Gender

Date of Birth

Address

Telephone

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